SCLERAL CONTACT LENS FITTING AND TROUBLESHOOTING. Lacey Haines, BSc, OD PhD Candidate November 14, 2014

Transcription

1 SCLERAL CONTACT LENS FITTING AND TROUBLESHOOTING Lacey Haines, BSc, OD PhD Candidate November 14, 2014

2 FINANCIAL DISCLOSURES I have no financial interest in the content of this talk I would like to thank Coopervision for their sponsorship

3 OUTLINE Introduction Brief Hx Nomenclature Advantages & Disadvantages Indications & Contraindications Fitting Initial Consultation Fitting Methods Insertion & Removal Lens Assessment Troubleshooting Complications van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from:

4 INTRODUCTION

5 BRIEF HISTORY 1508 da Vinci Enclosing reservoir of fluid over cornea Concept of optical neutralization Fick First practical contact lenses Scleral lenses made of blown glass shells Ezekiel First practical scleral lenses Made of oxygen permeable material Today High Dk materials Computer assisted manufacturing processes Problems with first scleral contact lenses Hypoxia and manufacturing issues Oxygen permeable scleral lenses Improved physiological ocular response but further development postponed with advancements in corneal GPs and soft (hydrogel) contact lenses High Dk Materials Better comfort, longer wearing time, broader indications Improved Manufacturing Technology More reproducible, more accurate, less expensive More complex designs 1. van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from: 2. Schornack MM, Patel SV. Scleral lenses in the management of keratoconus. Eye and Contact Lens. 2010;36(1): Pullum K, Buckley R. Therapeutic and ocular surface indications for scleral contact lenses. Ocular Surface. 2007;5(1): Romero-Jiménez M, Flores-Rodríguez P. Utility of a semi-scleral contact lens design in the management of the irregular cornea. Contact Lens and Anterior Eye Visser E-, Visser R, Van Lier HJJ. Advantages of toric scleral lenses. Optometry Vision Sci. 2006;83(4):233-6.

6 SCLERAL LENS DESIGN Scleral zone (Haptic/Edge) Limbal/Transition zone Corneal (optic) zone Limbal/Transition zone Scleral zone (Haptic/Edge)

7 SCLERAL LENS DESIGN Peripheral Curve Scleral zone (Haptic/Edge) Limbal/Transition zone Corneal (optic) zone

8 SCLERAL LENS NOMENCLATURE Classification Size Fitting Relationship With Cornea With Sclera Decreased tear reservoir Increased corneal bearing Corneo-scleral/ corneo-limbal/ limbal mm Corneal bearing Scleral touch Semi-scleral mm Corneal touch Scleral bearing Mini-scleral Full scleral mm mm Minimal corneal clearance Maximal corneal clearance Scleral bearing Scleral bearing Based on average corneal diameter (12.8mm) 1,2 Increased tear reservoir Increased scleral bearing van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from: Barnett M, Mannis MJ. Contact lenses in the management of keratoconus. Cornea. 2011;30(12):

9 ADVANTAGES Corneal clearance Optical neutralization Corneal protection Hydration Decrease scarring Fitting of irregular corneas Comfort No lid interaction with lens edge Bearing of lens on sclera (less sensitive) Large optic zone Alternative to corneal surgery Relief of pain & photophobia, general increase in quality of life Severinsky B, Millodot M. Current applications and efficacy of scleral contact lenses - A retrospective study. Journal of Optometry. 2010;3(3): ; Barnett M, Mannis MJ. Contact lenses in the management of keratoconus. Cornea. 2011;30(12): ; Segal O, Barkana Y, Hourovitz D, Behrman S, Kamun Y, Avni I, et al. Scleral contact lenses may help where other modalities fail. Cornea. 2003;22(4): ; Visser E-, Visser R, Van Lier HJJ, Otten HM. Modern scleral lenses part I: Clinical features. Eye and Contact Lens. 2007;33(1):13-20.; Visser E-, Visser R, Van Lier HJJ, Otten HM. Modern scleral lenses part II: Patient satisfaction. Eye and Contact Lens. 2007;33(1):21-5.; Ye P, Sun A, Weissman BA. Role of mini-scleral gas-permeable lenses in the treatment of corneal disorders. Eye and Contact Lens. 2007;33(2):111-3.; Schornack MM, Patel SV. Scleral lenses in the management of keratoconus. Eye and Contact Lens. 2010;36(1):39-44.; Pecego M, Barnett M, Mannis MJ, Durbin- Johnson B. Jupiter scleral lenses: The UC Davis Eye Center experience. Eye and Contact Lens. 2012;38(3): ; Romero-Jiménez M, Flores-Rodríguez P. Utility of a semi-scleral contact lens design in the management of the irregular cornea. Contact Lens and Anterior Eye ; Pullum K, Buckley R. Therapeutic and ocular surface indications for scleral contact lenses. Ocular Surface. 2007;5(1):40-9.; Smith GT, Mireskandari K, Pullum KW. Corneal swelling with overnight wear of scleral contact lenses. Cornea. 2004;23(1):29-34.; Pullum KW, Whiting MA, Buckley RJ. Scleral contact lenses: The expanding role. Cornea. 2005;24(3): ; Weyns M, Koppen C, Tassignon M-. Scleral contact lenses as an alternative to tarsorrhaphy for the long-term management of combined exposure and neurotrophic keratopathy. Cornea ; Rosenthal P, Croteau A. Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty. Eye and Contact Lens. 2005;31(3):130-4.; Alipour F, Kheirkhah A, Jabarvand Behrouz M. Use of mini scleral contact lenses in moderate to severe dry eye. Contact Lens and Anterior Eye. 2012;35(6):272-6.; Jacobs DS. Update on scleral lenses. Curr Opin Ophthalmol. 2008;19(4):

10 DISADVANTAGES Decreased tear exchange Reduced oxygen availability to cornea Increased cost Insertion and removal challenges Size can be intimidating for patient Handling (?) Scleral lens more fragile Some patients find it easier Complicated fitting process (?) Increased time required for fitting Time for lens to settle More visits required to finalize fit Barnett M, Mannis MJ. Contact lenses in the management of keratoconus. Cornea. 2011;30(12): ; Weyns M, Koppen C, Tassignon M-. Scleral contact lenses as an alternative to tarsorrhaphy for the long-term management of combined exposure and neurotrophic keratopathy. Cornea ; Pullum KW, Whiting MA, Buckley RJ. Scleral contact lenses: The expanding role. Cornea. 2005;24(3): ; Pullum K, Buckley R. Therapeutic and ocular surface indications for scleral contact lenses. Ocular Surface. 2007;5(1):40-9.; Romero-Jiménez M, Flores- Rodríguez P. Utility of a semi-scleral contact lens design in the management of the irregular cornea. Contact Lens and Anterior Eye ; Segal O, Barkana Y, Hourovitz D, Behrman S, Kamun Y, Avni I, et al. Scleral contact lenses may help where other modalities fail. Cornea. 2003;22(4): ; Smith GT, Mireskandari K, Pullum KW. Corneal swelling with overnight wear of scleral contact lenses. Cornea. 2004;23(1):29-34.

11 INDICATIONS Two main indications take advantage of the large tear reservoir created by corneal vaulting unique to scleral lenses 1. Vision Improvement for Irregular Corneas Ectasia Post-surgical Scarring 2. Corneal Protection Hydration Protection from lids and lashes Ocular surface diseases Corneal dystrophies or degenerations Severinsky B, Millodot M. Current applications and efficacy of scleral contact lenses - A retrospective study. Journal of Optometry. 2010;3(3):158-63; Pecego M, Barnett M, Mannis MJ, Durbin-Johnson B. Jupiter scleral lenses: The uc davis eye center experience. Eye and Contact Lens. 2012;38(3): ; Barnett M, Mannis MJ. Contact lenses in the management of keratoconus. Cornea. 2011;30(12): ; Weyns M, Koppen C, Tassignon M-. Scleral contact lenses as an alternative to tarsorrhaphy for the long-term management of combined exposure and neurotrophic keratopathy. Cornea ; Alipour F, Kheirkhah A, Jabarvand Behrouz M. Use of mini scleral contact lenses in moderate to severe dry eye. Contact Lens and Anterior Eye. 2012;35(6):272-6.; Pullum KW, Whiting MA, Buckley RJ. Scleral contact lenses: The expanding role. Cornea. 2005;24(3): ; Segal O, Barkana Y, Hourovitz D, Behrman S, Kamun Y, Avni I, et al. Scleral contact lenses may help where other modalities fail. Cornea. 2003;22(4): ; Visser E-, Visser R, Van Lier HJJ, Otten HM. Modern scleral lenses part I: Clinical features. Eye and Contact Lens. 2007;33(1):13-20.; Visser E-, Visser R, Van Lier HJJ, Otten HM. Modern scleral lenses part II: Patient satisfaction. Eye and Contact Lens. 2007;33(1):21-5.; Smith GT, Mireskandari K, Pullum KW. Corneal swelling with overnight wear of scleral contact lenses. Cornea. 2004;23(1):29-34.; Pullum K, Buckley R. Therapeutic and ocular surface indications for scleral contact lenses. Ocular Surface. 2007;5(1):40-9.; Rosenthal P, Croteau A. Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty. Eye and; ontact Lens. 2005;31(3):130-4.

12 OTHER INDICATIONS Failure of other lens designs Stability Discomfort VA High refractive error Vocational/avocational needs Active lifestyle Sports Eg. Water sports Dusty environment van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from: #%7B%22ImageId%22%3A %7D Pecego M, Barnett M, Mannis MJ, Durbin-Johnson B. Jupiter scleral lenses: The uc davis eye center experience. Eye and Contact Lens. 2012;38(3): ; Romero- Jiménez M, Flores-Rodríguez P. Utility of a semi-scleral contact lens design in the management of the irregular cornea. Contact Lens and Anterior Eye ; Schornack MM, Patel SV. Scleral lenses in the management of keratoconus. Eye and Contact Lens. 2010;36(1):39-44; Pullum KW, Whiting MA, Buckley RJ. Scleral contact lenses: The expanding role. Cornea. 2005;24(3):269-77; van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from:

13 CONTRAINDICATIONS Low endothelial cell count Suggested minimum of 800 cells/mm 2 Advanced stages of Fuch s Corneal transplant where graft rejection is a concern Inflamed conjunctiva Lack of dexterity for insertion and removal 1. Barnett M, Mannis MJ. Contact lenses in the management of keratoconus. Cornea. 2011;30(12): Rosenthal P, Croteau A. Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty. Eye and Contact Lens. 2005;31(3): van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from:

14 SCLERAL LENS FITTING

15 INITIAL CONSULTATION: CONSIDERATIONS Know indications and contraindications to identify good and poor candidates Know advantages and disadvantages to educate patient and ensure ScCL is right for them Set appropriate patient expectations Do not promise outcomes before lens is applied Do not focus on size of lens or rigid material Discuss the cooling and refreshing feeling instead

16 INITIAL CONSULTATION: ASSESSMENT Baseline topography and pachymetry Helpful for monitoring ocular health Depending on fitting method, may use this information for initial lens selection Extensive Hx of past and current Tx Ensure any current Tx will not be affected or have an effect on ScCL wear Eg. use of Rx eye drops Extensive SLE Thoroughly detail and document Photography if possible

17 SCLERAL LENS FITTING METHODS Diagnostic Fitting with Preformed Lenses Most common and recommended technique Empirical Fitting Not feasible without scleral topography Impression Technique Expensive Specialized equipment Future Directions Topography of anterior sclera Photo: Randy Kojima

18 DIAGNOSTIC FITTING: INITIAL LENS SELECTION Choose general design Oblate corneas reverse geometry design Choose LD based on HVID Generally ~16mm Sag selection: 1. Side profile 3 sizes or go to lenses for each lens diameter: Small, medium and large sag 2. Fitting guide BOZR does not correlate well with K readings 3. OCT Use AS-OCT to determine sag of eye at a particular chord length related to the diameter of the ScCL Case Example van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from: mono/4/.

19 RELATIONSHIP BETWEEN CORNEAL TOPOGRAPHY AND SCCL BASE CURVE Schornack & Patel (2010) Jupiter scleral contact lens No relationship Romero-Jimenez & Flores-Rodriguez (2012) Rose K2 XL semi-scleral contact lens Differences in central K readings and lens BOZR: Smaller for patients with keratoconus and corneal ring segments Larger for patients with PMD, keratoplasty, and post- LASIK ectasia Central cornea flatter Forced to fit steeper BOZR to increase sagittal depth

20 CASE EXAMPLE: SCCL FITTING WITH OCT KD is a 19 year old male with bilateral keratoconus. The right eye was stable with no symptoms. The left eye was more advanced and caused visual distortions He had corneal cross-linking surgery with INTACS insertion performed in the left eye 4 months prior to being fit with contact lenses His subjective Rx OS was: x155 (6/18+) Slit lamp exam showed double segment INTACS and central corneal striae in the left eye, but otherwise no other concerns Visante OCT (Zeiss Meditech, Germany) anterior segment imaging

21 ANTERIOR SEGMENT OCT OF KD S LEFT EYE The calipers show the sagittal depth of the eye at a 15.8mm chord.

22 CASE EXAMPLE Sagittal depth at 15.8mm chord = 4.24mm Added depth for vaulting = 0.25mm Added depth for settling = 0.10mm Calculated initial diagnostic lens: 4.24mm +0.35mm 4.59mm Initial MSD 15.8mm diagnostic lens sag = 4.60mm Lens power: -2.50D (6/6-) Fit assessment: Good centration Complete corneal and limbal clearance Scleral alignment

23 MSD LENS WITH GOOD CORNEAL AND LIMBAL CLEARANCE ON AN EYE WITH CORNEAL CROSS-LINKING AND DOUBLE SEGMENT INTACS

24 EFFICIENCY OF SCCL FITTING METHODS Gemoules (2008) Used sag measurements from Visante OCT to determine sag of initial trial lens selected Average of 1.7 attempts per patient Used small # of patients (n=9) and not clear on exact method Gemoules G. A novel method of fitting scleral lenses using high resolution optical coherence tomography. Eye and Contact Lens. 2008;34(2):80-3.

25 EFFICIENCY OF SCLERAL LENS FITTING Study Schornack & Patel (2010) Pecego et al. (2012) Romero- Jimenez & Flores- Rodriguez (2013) Lens Design Subjects # Visits # Trial Lenses # Ordered Lenses Jupiter Keratoconus Jupiter Various Rose K2 XL Semi- Scleral Various Schornack MM, Patel SV. Scleral lenses in the management of keratoconus. Eye and Contact Lens. 2010;36(1):39-44.; Pecego M, Barnett M, Mannis MJ, Durbin- Johnson B. Jupiter scleral lenses: The UC Davis Eye Center experience. Eye and Contact Lens. 2012;38(3): ; Romero-Jiménez M, Flores-Rodríguez P. Utility of a semi-scleral contact lens design in the management of the irregular cornea. Contact Lens and Anterior Eye

26 EXAM ROUTINE 1. Insert lens 2. Immediate initial assessment Blue penlight useful Check for insertion bubbles Gross fit evaluation Central touch Peripheral compression and toric patterns 3. Lens assessment after settling Settling period can vary widely between patients and lens designs Recently published: Most settling within 4 hours Consider fitting one eye at a time Wait at least 30 min, but allow room for more settling van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from:

27 EXAM ROUTINE CONTINUED 4. Remove lens Do this yourself to assess presence or absence of suction 5. Repeat as needed until final lens parameters determined Follow fitting guide or speak to lab consultant to make appropriate lens modifications 6. Assess eye without lens Leave no mark behind Philosophy at BFS according to Lynette Johns Cornea: SPK, edema, neovascularization Conjunctiva: hyperemia, staining, indentation

28 INSERTION Prepare lens Clean and rub with GP solution to hydrate Rinse thoroughly with preservative free (pf) saline Place lens on plunger (or ring applicator or O-ring) Fill bowl of lens with pf saline Swirl Fl strip in solution

29 INSERTION Prepare patient Discuss process Raise chair and place paper towel on patient s lap Patient leans forward, looking straight down with chin tucked in Provide appropriate fixation target SynergEyes UltraHealth Fitting Guide

30 REMOVAL Ease of removal can indicate suction Do not administer solution first Plunger is recommended Reduce IOP spike Hold lids Place plunger on lower half of lens Remove by pulling lens away from eye and up Examine eye without lens on slit lamp van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from:

31 SCLERAL LENS ASSESSMENT Central corneal clearance Ideally ~250µm Use optic section or OCT Limbal clearance Ideally at least 50µm Use optic section or OCT Scleral landing zone No compression/ blanching or impingement Check for debris build up on front surface and in post-lens tear layer

32 CORNEAL CLEARANCE

33 TROUBLESHOOTING AND COMPLICATIONS

34 SCLERAL LENS FITTING CHALLENGES Romero-Jimenez & Flores-Rodriguez (2013) Rose K2 XL semi-scleral Cause for reordered lenses # Lenses % Increased edge lift 3 25 Decreased edge lift 3 25 Steeper BOZR 5 42 Increased power 1 8 Edge lift: Evaluation is a learning process, unavoidable BOZR: Could be avoided if lens was allowed longer settling time at fitting visit (eg. 2 hours)

35 SCLERAL LENS FITTING CHALLENGES Complications Segal et al. (2003) Mild conjunctival hyperemia in 13 of 59 eyes Resolved after 1 month (continued lens wear) Visser et al. (2007) % of eyes with lens-related complication: Bulbar conjunctival hyperemia: 20.8% Corneal staining: 6.7% Corneal edema: 6.7% Palpebral signs: 6.3% Limbal hyperemia: 2.1% Corneal vascularization: 1.1%

36 TROUBLESHOOTING & COMPLICATIONS Bubbles Insertion Most common cause of bubbles Solutions: Re-educate on insertion technique Do not overfill lens prior to insertion Use more viscous pf solution for insertion Haptic misalignment More common with larger lenses Solutions: Toric peripheral curves Smaller lens diameter van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from:

37 TROUBLESHOOTING & COMPLICATIONS Compression Pressure on conjunctival tissue Results in blanching Solutions: Increase edge lift/flatten periphery Steepen periphery and lift limbal zone Impingement Pinching of conjunctival tissue Results in conjunctival staining Can lead to conjunctival hypertrophy Solution: Increase edge lift/flatten periphery van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from: u/mono/4/.

38 TROUBLESHOOTING & COMPLICATIONS Suction Can cause difficulty with lens removal or edema Solutions: Lubricate well and use upper lid to break suction Flatten peripheral curves Edge Lift Use Fl to identify Can cause discomfort (lens awareness), bubbles, and debris in chamber Solutions: Toric haptic Smaller lens design van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; Available from:

39 TROUBLESHOOTING & COMPLICATIONS Chamber Debris More likely to occur with haptic misalignment Look for tear exchange with Fl insertion with lens in place Solutions: Toric haptic Decrease edge lift/steepen periphery Eliminate preservatives in care system Use viscous solution with insertion Description Association Solution White, fluffy Mucous, GPC Use pf care system Cloudy Atopy Rx MCS or soft steroid Lipid droplets Poor lid hygiene Educate patient on lid care

40 TROUBLESHOOTING & COMPLICATIONS Front Surface Debris Inquire about hand soap, creams, make up, etc. Solutions: Increase ocular lubrication Remove lens for cleaning midday Use cotton swab and saline to rub FS with lens in eye Address lid hygiene Send lens to lab for polishing

41 TROUBLESHOOTING & COMPLICATIONS Inadequate Central Clearance Bearing on cornea may cause epithelial injury or lens adherence Solution: Increase ScCL sag (steepen BOZR) Inadequate Limbal Clearance May cause limbal epithelial hypertrophy, SPK, and discomfort Solutions: Increase lift in transition zone Increase chamber size

42 TROUBLESHOOTING & COMPLICATIONS Pinguecula Note location relative to limbus Solutions: Avoid by fitting smaller LD Rest haptic on top, use toric PC Vault over Loose Conjunctival Tissue Transient vs Permanent Solutions: Do nothing (transient) Surgical removal (permanent)

43 TROUBLESHOOTING & COMPLICATIONS Hypoxia Can cause edema and neovascularization Solutions: Decrease wear time Increase tear exchange Re-fit into smaller lens design Solution Toxicity May cause decreased comfort, diffuse hyperemia, photophobia Can result from inappropriate solution used for insertion or failure to rinse inside of lens Solution: Non-preserved saline or unit dose inhalation saline

44 TROUBLESHOOTING & COMPLICATIONS Residual Astigmatism Determine with sphere-cyl over-refraction From lens flexure Determine with over-keratometry Solution: Increase centre thickness From internal astigmatism Lenticular or abnormal posterior corneal shape (eg. INTACS) Solutions: Front toric design Specs over ScCLs

45 FUTURE DIRECTIONS Fitting and assessment with OCT Scleral topography Sagittal depth measurements More indications for regular corneas High ametropia Presbyopes Increasing complexity of FS optics Multifocal designs Higher order aberrations Custom wavefront corrections Optic zone decentration

46 RESOURCES A Guide to Scleral Lens Fitting Eef van der Worp The GP Lens Institute (GPLI) Scleral Lens Education Society Clinical Manual of Contact Lenses (4 th ed.) Edward S. Bennett, Vinita Allee Henry Scleral Lens Fit Assessment Guide

47 THANK YOU!